Intravenous immunoglobulin for idiopathic thrombocytopenic purpura (ITP) in childhood

IgG-SRK (identical with Sandoglobulin) is a polyvalent IgG concentrate obtained by modified alcohol cryoprecipitation, including mild acidification at pH 4. This product was given in high doses intravenously for the treatment of six children with acute ITP, four children with intermittent ITP, and three children with severe chronic idiopathic thrombocytopenic purpura (ITP). An impressive initial response was observed in all patients, the extent of which may be of prognostic significance in acute ITP. Maintenance therapy was required in two of six patients with acute ITP, in three out of four patients with intermittent ITP, and in all of the patients with severe chronic ITP. In the cases of severe chronic ITP, the disease could not be adequately controlled over long periods of time, but bleeding episodes subsided or became considerably less frequent. Although little is known of the effects of IgG-SRK, possible mechanisms were discussed. It is emphasized that a new model has been discovered to study the interrelations between structure and function of human immunoglobulin molecules.

High doses of gamma globulin and methylprednisolone therapy for idiopathic thrombocytopenic purpura in children

In four children with chronic idiopathic thrombocytopenic purpura (ITP), high doses of gamma globulin or methylprednisolone were effective in increasing platelet counts transiently, yet there was no quantitative relationship between the platelet responses to these two therapies. This finding suggests a qualitative difference in the mechanisms of increasing platelets by the two drugs. High doses of gamma globulin and methylprednisolone showed a synergistic effect on the initial and maximal platelet responses, suggesting an intensification of the effect of gamma globulin by methylprednisolone. This combination therapy should be clinically useful, particularly in the control of acute haemorrhage or in preparations for emergency surgery.

Primary hepatic lymphoma presenting as symptomatic immune thrombocytopenic purpura

A 33-year old Arabian man presented with idiopathic thrombocytopenic purpura that did not respond to steroid treatment or splenectomy. A routine liver scan performed after splenectomy showed a large mass in the liver. Four years later, massive gastrointestinal bleeding led to an emergency laparotomy, which revealed well-differentiated lymphocytic lymphoma extending from the liver to the fundus and lesser curvature of the stomach. A partial gastrectomy was performed. With chemotherapy the liver mass resolved and the platelet counts have normalized for the past 30 months.

Clinical effect of intravenous immunoglobulin on chronic idiopathic thrombocytopenic purpura

High dose immunoglobulin infusions showed a marked effect on platelet counts in eight out of nine chronic ITP patients and in one SLE patient. In the comparison of different IgG-preparations, the pepsin treated IgG F (ab')2 showed no platelet elevation while the sulfonated did. The elevated platelet count could not be maintained after discontinuation of IgG infusions, but in six out of ten patients the platelet level remained above the pretreatment values. This new treatment seems to be safe and effective in adulthood ITP.

Idiopathic thrombocytopenic purpura

Idiopathic thrombocytopenic purpura occurs at all ages, in acute and chronic forms. Children mainly have the acute form, which usually follows a recent viral illness, occurs equally in both sexes, and generally resolves within six months. Chronic idiopathic thrombocytopenic purpura occurs more often in adults, often has an insidious onset, and shows a three:one female preponderance. Both forms are now thought to be due to an antiplatelet antibody, usually of the IgG class (platelet-associated IgG), which coats autologous platelets and leads to their phagocytosis and destruction by the reticuloendothelial system. In most patients, the spleen is the major site of the production of this platelet antibody and the destruction of the platelets. Many methods have been developed to detect this antiplatelet factor in the serum and on the platelets of patients with idiopathic thrombocytopenic purpura. Recent methods are becoming highly sensitive and may soon be simple and fast enough for routine clinical use and should significantly aid the diagnosis and management of these patients. Platelet-associated IgG levels appear significantly higher in patients with idiopathic thrombocytopenic purpura than in normal subjects, and in patients with nonimmune thrombocytopenia. Higher levels are also seen in children than in adults, and in acute cases than in chronic ones. Platelet-associated IgG levels also vary inversely with platelet count and platelet life span, can predict the disease course and response to therapy, and may predict neonatal consequences of maternal idiopathic thrombocytopenic purpura. Evidence of other alterations in immune status, as well as alterations in platelet function and HLA associations, remains controversial. Classic treatment with corticosteroids and splenectomy remains highly successful in most cases. More recent therapies include the use of immunosuppressants and alkaloid-coated platelets, plasma-exchange transfusion, and high-dose immunoglobulin. Overall, fewer than 5 percent of patients have severe hemorrhage or refractory or fatal disease.

Intravenous and standard immune serum globulin preparations interfere with uptake of 125I-C3 onto sensitized erythrocytes and inhibit hemolytic complement activity

Antibody-sensitized sheep erythrocytes were used as a model to determine the effects of therapeutic immune serum globulin (ISG) preparations on the ability of this particulate activator to fix C3 and initiate hemolysis. Both standard and intravenous forms of ISG inhibit uptake of 125I-C3, presumably by competing for the deposition of "nascent" C3b molecules onto the erythrocytes. Both forms of ISG also inhibit hemolytic activity of whole serum or purified complement components. The inhibition appears to be a specific property of IgG itself, since similar inhibition was not caused by equivalent concentrations of human serum albumin, and was not affected by the buffer in which the ISG was dissolved. Interference with C3 uptake onto antibody-sensitized platelets and/or inhibition of hemolytic complement activity could contribute to the efficacy of high dose intravenous ISG in idiopathic thrombocytopenic purpura.

Neonatal autoimmune thrombocytopenia: role of high-dose intravenous immunoglobulin G therapy

High-dose intravenous immunoglobulin G (IVIgG) therapy results in a rapid reversal of thrombocytopenia in over 80% of children with acute immune thrombocytopenic purpura (ITP). Comparable results were observed in eleven infants with an analogous condition, neonatal autoimmune thrombocytopenia (NATP), who received IVIgG (2 g/kg body weight) administered alone (n = 6) or in combination with steroids (n = 5). The median platelet count pre-IVIgG therapy was 25 X 10(9)/l (range 5 to 74 X 10(9)/l). The overall response rate to IVIgG therapy, administered alone or in combination with steroids was 75% (12 of 16 treatment episodes). A good response to therapy was defined as an increase in the platelet count to greater than or equal to 50 X 10(9)/l and at least twice the pre-treatment value at 48 h after completion of the IVIgG infusion. The rapid and generally excellent response to IVIgG therapy in infants with NATP suggests that this treatment approach should be considered as first-line therapy for severely thrombocytopenic infants with this self-limiting but potentially serious disorder.

Complete resolution of life-threatening hemangioma by embolization and corticosteroids

A case is presented in which congestive heart failure and thrombocytopenia were complications of an inoperable hemangioma in a neonate. Selective embolization of the hemangioma in the patient achieved significant diminution in the congestive failure and tided this infant through the first few days of life while awaiting positive effects from the steroids and external compression. The combined treatment modalities of selective embolization, external compression, and short course of low-dose systemic steroids resulted in a rapid and complete resolution of this life-threatening problem.

Hemolysis due to high-dose intravenous gammaglobulin treatment for patients with idiopathic thrombocytopenic purpura

Two adult patients with chronic idiopathic thrombocytopenic purpura (ITP) were treated with high-dose intact immunoglobulin (high-dose IgG). Haptoglobin levels in both cases declined significantly during high-dose IgG, following the increase in platelet counts to normal level. In one of them apparent hemolytic anemia was observed. The findings strongly support the hypothesis that the effect of high-dose intact IgG treatment on ITP patients is due to sequestration of IgG-coated autologous red blood cells by the reticuloendothelial system and the saturation of the macrophages by red blood cells.

Efficacy of intravenous gamma globulin in autoimmune-mediated pediatric blood dyscrasias

Sixteen pediatric patients diagnosed with a variety of autoimmune-mediated hematocytopenias were treated with one to 50 courses of intravenous gamma globulin (IVIG), pH 4.25, over the course of one to 30 months. Thirteen patients had immune thrombocytopenic purpura (ITP), two had autoimmune neutropenia, and one had autoimmune hemolytic anemia. In one patient, chronic ITP was associated with systemic lupus erythematosis, and in a second patient, acute ITP was the presenting manifestation of infection with human immunodeficiency virus. Initial therapy consisted of 400 mg/kg/dose daily for five days for the first seven patients treated, and 1,000 mg/kg/dose daily for two days for the remaining nine patients. In 15 of 16 patients, there was a response to IVIG therapy. In nine of 16 patients, maintenance IVIG therapy for two to more than 30 months was required. Minimal toxicity was experienced in four of 210 separate infusions. Data are presented to support the use of IVIG in the management of childhood autoimmune disorders.

Clinicopathologic and prognostic features of chronic idiopathic thrombocytopenic purpura in adult Chinese patients: an analysis of 220 cases

To determine the clinicopathologic and prognostic features of chronic idiopathic thrombocytopenic purpura (ITP) in adult Chinese patients, we conducted a retrospective analysis of 220 patients seen at a single center over a 40-year period. The female-to-male ratio was 4:1, with a mean age of 42.1 +/- 1.3 years, a mean platelet count of 33.7 +/- 2.3x10(9)/l, and a mean follow-up of 116 +/- 7 months. Initial steroid treatment was required in 142 patients, 67 of whom (47.2%) achieved complete remission (CR). At 470 months, 46% patients remained in CR. Splenectomy was performed in 37 patients: in 23 patients due to primary steroid refractoriness and in 7 patients due to disease relapse following initial CR with steroids. In seven patients, data on response to steroids prior to splenectomy were not available. Splenectomy for steroid nonresponders resulted in an inferior CR rate (13 of 23, 56%) as compared with that for relapses after steroid treatment (7 of 7, 100%) (P<0.05). Compared with patients with negative antinuclear antibody (ANA), those who were ANA positive had similar responses to steroids, but significantly shorter remission after splenectomy (P<0.01). In conclusion, Chinese patients with ITP could maintain long-term remission after steroid therapy and splenectomy. In addition, primary steroid refractoriness and positive ANA were bad prognostic factors of the subsequent response to splenectomy.

Use of intravenous gamma globulin in children and adolescents with idiopathic thrombocytopenic purpura and other immune thrombocytopenias

Approximately 85 to 90 percent of cases of idiopathic thrombocytopenic purpura (ITP) in children are of the acute, self-limited variety that generally occurs after a viral infection. The remaining 10 to 15 percent of children with this disorder have the chronic (autoimmune) type of ITP. For these patients, splenectomy is often the recommended treatment if severe bleeding occurs and platelet counts remain below 40,000/mm3. However, splenectomy has associated risks and the response to this surgery cannot always be predicted. Intravenous gamma globulin (IVIG) has proven useful as an alternative to splenectomy, especially in children who are considered too young for splenectomy or in those in whom there is no response to splenectomy. It should be noted that booster shots are frequently required and the patient's ITP may become refractory. IVIG may also be useful in preparing a child with ITP for splenectomy and in treating children or adolescents with ITP who have central nervous system or other serious hemorrhages. Although IVIG is not always effective in raising the platelet count, it does provide a very useful alternative method of treating this disorder.

Route of delivery for patients with immune thrombocytopenic purpura

Over the past 15 years, we managed 19 pregnancies in 18 women afflicted with immune thrombocytopenic purpura. Our policy has been to treat the mother with corticosteroids if her platelet count was below 100 X 10(9)/L and to use cesarean section only for obstetric indications; 14 patients received corticosteroids. The perinatal outcomes were intrauterine fetal death (two), neonatal death (0), and live birth (17). The methods of delivery for the 17 live-born infants were spontaneous vaginal (seven), low forceps or midforceps (five), cesarean section (five). Although seven of the live-born infants (41%) were thrombocytopenic (less than 100 X 10(9)/L), only two received therapy, and none suffered significant hemorrhagic morbidity. Maternal treatment with corticosteroids did not affect the neonatal platelet count, nor was there a correlation between maternal and neonatal platelet counts. On the basis of our experience, we think that cesarean section is not routinely indicated as the method of delivery for parturient patients with immune thrombocytopenic purpura.

Immunodeficiency-associated thrombocytopenic purpura (IDTP). Response to splenectomy

Immunodeficiency-associated thrombocytopenic purpura (IDTP) is a feature of the acquired immunodeficiency syndrome--related complex. Current therapeutic modalities for IDTP include splenectomy and the administration of corticosteroids or other agents. Empiric treatment of IDTP has been analogous to that for immunologic thrombocytopenic purpura (ITP). The present report reviews 15 patients who underwent splenectomy for IDTP, demonstrates the successful use of surgical therapy, and defines our indications for splenectomy in the treatment of this disorder. Thirteen of 15 patients had initially failed to respond to steroid therapy. Fourteen patients (93%) initially responded to splenectomy, with platelet counts increasing to 150 X 10(9)/L (150,000/mm3) or greater. A continuing complete response was achieved in nine patients (60%) following splenectomy. After postsurgical adjunctive therapy, durable remission was achieved in 73% (11/15) of the patients. Complications occurred in three patients, and there were no deaths. The mean follow-up was 12.4 months. Splenectomy may be performed in the treatment of IDTP with acceptable morbidity and likelihood of response.

Thrombotic thrombocytopenic purpura: understanding a disease no longer rare

Serial studies of plasma samples from patients during episodes of thrombotic thrombocytopenic purpura (TTP) have often shown either the presence of unusually large (UL) von Willebrand factor (vWf) multimers or, alternatively, absence of the largest plasma vWf forms. The presence of ULvWf multimers in TTP patient plasma may reflect impaired processing of the ULvWf forms released from endothelial cells. The disappearance of ULvWf and large vWf multimers in some TTP patient plasma samples during acute TTP episodes may be predominantly because these ULvWf forms, along with the largest vWf multimers, bind to platelets and cause aggregation. Serial flow cytometry studies of EDTA-whole blood samples from patients with initial episode, intermittent, and chronic relapsing types of TTP confirm that vWf is the likely aggregating agent, perhaps in association with fluid shear stress. The amount of vWf bound to single platelets has been found to be significantly increased during TTP relapses relative to remission periods in patients with all types of TTP. A substance in normal platelet-poor plasma and the cryoprecipitate-depleted fraction of normal plasma (cryosupernatant) is capable in vitro of reversibly reducing the size of ULvWf multimeric forms released by endothelial cells into the somewhat smaller vWf multimers ordinarily in circulation. This activity has characteristics of a limited disulfide bond reductase. The process of ULvWf breakdown may be made irreversible by the tandem proteolysis, catalyzed by a vWf metalloproteinase, of partially reduced vWf multimers. Several patients with chronic relapsing TTP have decreased or absent plasma vWf metalloproteinase activity, apparently on a congenital basis. Adult initial episode and intermittent TTP patients have been found to have vWf metalloproteinase activity inhibited by an autoantibody during, but not after, TTP epidsodes.

Idiopathic thrombocytopenic purpura in pregnancy and neonatal period

In pregnancy and neonatal period both mother and child are endangered by bleeding complications due to maternal idiopathic thrombocytopenic purpura. Obstetrical and perinatal management therefore must aim at increasing maternal and fetal platelet count. In our paper six patients in nine pregnancies are reported. Two of them (five pregnancies) were treated with corticosteroids, four of the patients were successfully treated with i.v. immunoglobulins (IgG). Longterm steroid application and splenectomy during pregnancy may be hazardous for mother and fetus. IgG i.v. administration in contrast offers a new and safe way to control maternal and fetal platelet counts during pregnancy, delivery and the neonatal period.

Intravenous immunoglobulin administration in the treatment of severe chronic immune thrombocytopenic purpura

Human immunoglobulin was administered intravenously to nine adult patients having severe chronic immune thrombocytopenia purpura. The response in three patients was an increase in the platelet count to greater than 50,000/mm3, a hemostatically adequate level. Response was associated with a pretreatment platelet-associated immunoglobulin level of more than 5,000 molecules per platelet, and successful treatment resulted in a decrease in that level. In those patients with pretreatment platelet-associated immunoglobulin levels less than 5,000 molecules per platelet, there was neither a significant decrease in that level nor an increase in their platelet count. Immunoglobulin infusion may prove useful for selected patients with severe chronic immune thrombocytopenia.